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Pharmacy BenefactA B U L L E T I N F O R P H A R M A C Y S E R V I C E P R O V I D E R S F R O M A L B E R T A B L U E C R O S S

Number 600 • April 2016

High cost drug claim submission – manual Drug Claim Form versus direct billingAs a reminder, and in followup to Benefact Number 569, when the drug cost of a claim or the total claim cost is greater than $9,999.99, a manual Drug Claim Form must be completed and submitted to Alberta Blue Cross for processing. Examples of high cost drugs for which this could apply are Harvoni (28 days supply) and Sovaldi (28 days supply). Submitting a Drug Claim Form allows eligible claims to be adjudicated according to the member’s plan design.

At this time, due to CPhA and system limits, these high cost drug claims cannot be submitted to Alberta Blue Cross through our direct bill claim submission process. In addition, these claims should not be submitted through direct billing by splitting the claim using multiple service dates. Please be aware, however, that Alberta Blue Cross is committed to working on a resolution to streamline this manual process.

Drug Claim Form information

• Each Drug Claim Form includes a carbon copy for you to retain for your records.

• The Drug Claim Form is for pharmacy provider use only. Should members require a form for reimbursement, please have them contact Alberta Blue Cross Customer Services or visit our website for more information.

• If you require Drug Claim Forms, please contact our Provider Relations contact centre at 1-800-361-9632.

• For tips on how to properly complete a Drug Claim Form to ensure efficient processing, please see the following page.

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When you have questions:

For assistance with benefit or claim inquiries, please contact an Alberta Blue Cross Pharmacy Services Provider Relations contact centre representative at: 780-498-8370 (Edmonton and area) • 403-294-4041 (Calgary and area) • 1-800-361-9632 (toll free)FAX 780-498-8406 (Edmonton and area) • FAX 1-877-305-9911 (toll free)

Alberta Blue Cross offers online access to current Pharmacy Benefacts and supplemental claiming information to assist with the submission of your direct bill drug claims. Visit https://www.ab.bluecross.ca/providers/pharmacy-home.php

®*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association. ABC 82320.600 2016/04

For questions or concerns regarding the Drug Claim Form, please contact our Provider Relations contact centre toll free at 1-800-361-9632.

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Please indicate the reason you are submitting the Drug Claim Form. i.e. Claim Cost exceeds $9,999.99.

Provide the date of service, Rx and Tx number (if applicable), DIN, days supply, quantity, Product Selection Code and prescriber ID.

Please ensure the prescriber ID includes the applicable leading zeros.In the Previously Paid field, indicate costs paid for by other insurers and/or the Manufacturer for this claim. If there was no other coverage, please leave blank.

Include your provider number and contact information in case there are questions regarding the information provided on the Drug Claim Form.

Ensure you submit a cost breakdown of the prescription including Drug Cost + Upcharge 1, Upcharge 2 and the Professional Fee. All cost information should be compliant with the pricing in the Pharmaceutical Services Provider Agreement as outlined in Benefact 445.

Human Services 1976 Authorization or Vacation Authorization numbers should be entered here.

Ensure the member’s coverage information is complete and accurate.

Please provide a contact name and signature on the bottom in case there are questions regarding the information on the Drug Claim Form.